HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 09/28/2017t ri
:' 'DI �l�opment
rt Collins
� � P8 &►xe A281 N. ve.
_, i ® Fort Coums. W m=
- 971i.416.2T4Q -
- 970.224.5734 (taX)
Combustion Safety Tat Compliance Form
Replaeentent of Na%rai Draft Appliame s in E&ft Hot m
Address: _ (�� �+'� �-�^S-°'✓ � ---- Permit #:'�17a lo? S� l
Approved Agency:
I hereby attest that I have performed the foMming Combustion Safety Test m accordance with
i Fort Collins Combustion Safety Test GUide Version 5, February 2012.
TechnicianWame
Technician Signa
APPiiance Tested:
(print): �L-Iompany w1 CO
Data 9
D
Appliance RepIaced: I < [[ [ [ tc
Worst Case Conditions:
Spillage Duration (in seconds): _� Carbon Monoxide (Parts per million):
Pass Fail Date Tested:
Natural Conditions: r
SPAS setxxxis): J Se c_ Carbon !Monoxide (par#s per7)hm):_
Pass _Ix Fail
Date Tested -
(Faded test rejebw corrw7f m uml test parses under Natural CetrMam)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above Iisted Property and hereby acknowledge that my appliance
has &M a Combustion Safety Test wider worst -ease cow. I acknowledge that I have received a
combustion apPliance safety information sheet.
Owner's Name (print)
Owner's Signature Date
GIST. 4.25-t2